Almost all healthcare provider organizations undergo medical coding and billing audits. However, many of such audits do not reveal the real issues and hence are not effective. In this article we will discuss reasons for the same with particular focus on why RCM audits that put too much emphasis on coding errors fail to meet the expected goals.
Is your documentation and compliance level optimum?
Does your documentation quality meet federal standards?
Are you collecting the full reimbursement for the care you deliver?
Are you losing revenue due to RCM process gaps?
Typically claims submitted with no coding or billing errors should yield maximum reimbursement; but this may not always be the case. A claim with no errors may fetch the organization less revenue than it should and this can cause much more bottom-line damages than a denied claim. If you are wondering how that is possible, then read this complete article and it can be an eye-opener for your practice.
Under-coding and omissions are two key reasons why a claim with no coding error fetches you sub-optimal revenue. A claim generated from incomplete documentation may not have any ‘coding error’. However, it may generate lower reimbursement due to incomplete coding. Under-coding and omissions never get reported until an audit unearths them and audits that simply put emphasis on finding coding errors are unlikely to reveal these issues. Audits must bring out coding errors, equally important is to highlight areas that could yield higher reimbursements that are legally and ethically possible in a claim.
There are times when a procedure can be coded in couple different ways and both are correct but one yields higher reimbursements than the other. So coding for higher reimbursement becomes very important. This is another case where audits that put too much emphasis on coding errors fail to achieve desired goal.
Sometimes documentation may lack specificity or the details required for accurate and legally permissible reimbursements. The outcome of this most often surfaces as high query volume without the overall coding error percentage going up. This is typical case where coding errors are under control but reimbursements are lower than desired.
Here is how an organization can make sure that audits not only bring out coding errors, but also reveal how much reimbursement is missing due to incomplete or missing documentation. Organization’s Quality Policy definition is the ideal place to start working towards a solution. If the Quality Policy defines incomplete and missing documentation as bad quality, then an audit that complies with this policy will reveal such shortcomings and report the same.
Percentage of discharge disposition changes
Missed query opportunities
Changes to present on admission indicators
Sub-optimal usage of EMR software
Resource skill mismatch
Operational workflow gaps
Good audits typically expose operational workflow gaps too. For example, if more errors are identified in the collection of accurate discharge dispositions, there could be a workflow issue causing it, which comes out only in a comprehensive audit. RCM audits should not only address coding errors but also focus on the following aspects that can either yield higher reimbursements or minimize compliance issues and penalties.
Identify and classify under-coding and up-coding as errors
Identify instances of alternate coding routes that yield higher reimbursements
Identify and classify codes that lack specificity as a coding error
Missed query opportunities
Sub-Optimal usage of EMR software
Resource skill mismatches
Linking audits with CDI and other data points
Acusis is a leading Revenue Cycle Management auditing company in the United States. Acusis offers cost effective and result-oriented RCM consulting services. Acusis also offers comprehensive auditing services for your Revenue Cycle Management.
Acusis Revenue Cycle Management Consulting team has some of the best RCM experts in the industry who can quickly get involved with your revenue cycle processes and help you maximize your reimbursements.
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